Preventing and Managing Congenital Syphilis … and Managing Congenital Syphilis Infections Jeanne...
Transcript of Preventing and Managing Congenital Syphilis … and Managing Congenital Syphilis Infections Jeanne...
Preventing and
Managing
Congenital
Syphilis Infections
Jeanne S. Sheffield, MD
Maternal-Fetal Medicine
Johns Hopkins Medicine
Definition of Congenital Syphilis
for Surveillance
• Infants born with syphilis
• Stillbirths born to mothers with syphilis
• Infants born to mothers with untreated or
inadequately treated syphilis
Proven or Highly Probable CS
Any neonate with:
• an abnormal physical examination that is consistent with
congenital syphilis;
OR
• a serum quantitative nontreponemal serologic titer that is
fourfold higher than the mother’s titer;**
OR
• a positive darkfield test or PCR of lesions or body
fluid(s).
** The absence of a fourfold or greater titer for a neonate
does not exclude congenital syphilis.
Possible CS
Any neonate who has a normal PE and a serum quantitative
nontreponemal serologic titer ≤≤ fourfold the maternal titer
and one of the following:
• mother was not treated, inadequately treated, or has no
documentation of having received treatment;
OR
• mother was treated with erythromycin or a regimen other
than those recommended in these guidelines **
OR
• mother received recommended treatment <4 weeks before
delivery.** A women treated with a regimen other than recommended
in these guidelines should be considered untreated.
Congenital Syphilis Less Likely
Any neonate who has a normal physical examination and a
serum quantitative nontreponemal serologic titer equal to or
less than fourfold the maternal titer and both of the following
are true:
• mother was treated during pregnancy, treatment was
appropriate for the stage of infection, and treatment was
administered >4 weeks before delivery and
• mother has no evidence of reinfection or relapse.
Congenital Syphilis Unlikely
Any neonate who has a normal physical examination and a
serum quantitative nontreponemal serologic titer equal to or
less than fourfold the maternal titer and both of the following
are true:
• mother’s treatment was adequate before pregnancy and
• mother’s nontreponemal serologic titer remained low and
stable (i.e., serofast) before and during pregnancy and at
delivery (VDRL <1:2; RPR <1:4).
Why is Congenital Syphilis on the Rise?
• There was a 36% increase when
comparing 2015 to 2011
– 56% increase in primary and secondary
syphilis rates during the same time period
– 22% of the cases in 2014 had no prenatal
care
• If they had prenatal care, 43% did not receive
prenatal treatment
– 16% not tested
– 39% seroconverted during pregnancy
• 17% were treated <30 days prior to delivery
CDC STD Surveillance data 2015
Congenital Syphilis
• T. pallidum is transmitted across the
placenta from a pregnant woman to her
fetus
• May occur during any stage of syphilis and
in any trimester
• Manifestations may not be noted at birth
– Early lesions inflammatory
– Late lesions immunologic and destructive
Congenital Syphilis• The diagnosis is surprisingly difficult
– All infants born to mothers with reactive
syphilis serology should have an RPR or
VDRL performed on the serum (not umbilical
cord sample)
– No adequate IgM available at this time
– Physical exam : hydrops, HSM, jaundice,
rhinitis, pseudoparalysis, skin rash
– Examine the placenta and umbilical cord
– Darkfield microscopy if suspicious lesions or
available body fluids
Serologic Testing for Syphilis
• Serologic detection requires the detection
of two types of antibodies
– Non-treponemal antibodies
• Directed against lipoidal antigens
• RPR and VDRL, TRUST
– Treponemal antibodies
• Antibodies directed against T. pallidum proteins
• TP-PA, MHA-TP, FTA-ABS, EIAs, CIAs, MBIA
Benefits (and Problems) of Each
• Traditional
– Detects active infection
– High rate of biologic false positives so needs
confirmation
– Can miss early primary and treated infection
• Reverse sequence algorithm
– Detects early and treated infection
– Non-treponemal test needed to detect active
infection
– EIAs and CIAs are nonspecific with high false
positive rate
Identification of pregnant
women infected with syphilis• Screen ALL pregnant women
– First prenatal visit
– In many states, screen again at 28 weeks
and then again at delivery in high prevalence
communities
• No infant should ever be discharged from
the hospital without confirmation of
negative maternal serology
• Screen anyone who delivers a stillborn
infant after 20 weeks gestation
Fiumara N, et al. N Engl J Med
1952;247:48-54
Pregnancy Outcome in Relation to
Maternal Stage of Infection
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Preterm Perinatal
Death
Congenital
Syphilis
Healthy
Child
Primary or Secondary Early Latent Late Latent Uninfected
Congenital Syphilis at
Parkland Hospital 1988 to 1998
0% 10% 20% 30% 40% 50% 60%
Unknown (N=97)
Late Latent (N=27)
Early Latent (N=145)
Secondary (N=53)
Primary (N=26)
Stillbirth Congenital Syphilis
23%
60%
36%
7%
20%
Alexander JA, et al. Obstet Gynecol
1999; 93:5-8
Syphilis Therapy Efficacy by
Stage
0 4 2 0 6
100% 94.7% 98% 100% 98.2%
0%
20%
40%
60%
80%
100%
Prim
(27)
Sec
(75)
EL
(102)
LL
(136)
Total
(340)
Success Failure
Alexander JA, et al. Obstet
Gynecol 1999; 93:5-8
Syphilis Treatment Efficacy
by Gestational Age
1 0 0 0
100%93%100%93% 100%99%
4
2
0%
20%
40%
60%
80%
100%
<21
(126)
21 - 25
(51)
26 - 30
(59)
31 - 35
(46)
36 - 40
(28)
40 - 43
(3)
Weeks' gestation (N)
Success Failure
Sheffield JS et al. Am J Obstet Gynecol
Congenital Syphilis Following
Maternal Treatment in Pregnancy
• Case:control study of women receiving antepartum syphilis therapy.
• Delivery of an infected infant was associated with
– High VDRL titers at treatment and delivery
– Earlier maternal stage of syphilis
– Interval from treatment to delivery
– Delivery of an infant 36 weeks gestation
“He who knows Syphilis,
knows Medicine”
Sir William Osler(1849-1919)
Ricard Tennant Cooper (1912)
Wellcome Library, London
Final Message
• The State and Local Health Departments
are your allies in the fight against both
CZS and Congenital Syphilis
– Do not hesitate to contact them with any
questions. They are there to help with contact
notification, researching prior treatment and
helping interpret results
– If they contact you regarding a possible case,
follow up with them
– These are reportable diseases